In The News...Do Managed Care companies and HMO's discourage psychotherapy?

The short answer is, all too frequently, Yes! This is the conclusion of a study recently published in a psychology journal and publicized in newspapers and on TV. Furthermore, the article alleges that managed care companies push people to take medications, instead of psychotherapy, at least partly because medications may be cheaper overall. My own impression is both of these points are likely true, although at least sometimes this is well intended.

Managed Care companies exist for 3 main reasons: to control (or decrease) costs, to ensure that needed care is delivered most cost effectively, and to produce profits for the owners. These are not necessarily bad things and may be good. Health Maintenance Organizations (HMO's) and mental health"carve out" companies are the most extreme examples of managed care. These companies have been so "successful" that expenditures on mental health have reportedly decreased by more than 50% in the last 10 years even though expenditures in other areas of health care have grown, although more slowly than before managed care. This has been achieved by the following mechanisms: 1) denying or severely limiting care, 2) (intentionally or not) making the process of authorizing care and having it paid for so much hassle that patients and clinicians give up or settle for the little they can get, 3) reducing payments, 4) limiting or reducing which clinicians are on the approved list, 5) limiting the medication options (restrictive formularies), 6) not allowing or rarely allowing psychological testing, hospital or residential treatment, and lastly, 7) defining some conditions as not warranting treatment (eg, behavior problems, ADHD) or retreatment (eg, substance abuse) or as"chronic" (schizophrenia, autism) or pre-existing and thus uncovered. Managed Care Companies argue that these and other restrictions are legitimate and are financially required and ethical.

Clinical studies and experience show that psychotherapy is usually warranted for mental health disorders. Certain psychotherapy techniques have been shown best for certain conditions (eg, cognitive therapy or interpersonal therapy for major depression and exposure with response prevention for obsessive compulsive disorder). Some persons do better with psychotherapy than others and some people value and use the insight oriented therapies more successfully than others. Some people simply prefer the process of therapy and others prefer the use of medication. Mild conditions may require no treatment or only psychotherapy. The majority of persons with moderate to severe disorders typically do best with a combination of psychotherapy and medication while about 25% do best with therapy alone and about 25% do best with medicine alone. Psychiatrists, like myself, often combine psychotherapy and medication treatment while referring to a colleague for more in-depth psychotherapy when appropriate or needed.

In my view, informed consumers of mental health care and health care do not typically need a managed care company or other gatekeeper as an expensive middle man. These informed consumers who are seeking an educated partnership are who my practice is structured to serve. Managed care companies that help patients and clinicians, quickly and without hassle, connect up to provide suitable and optimal treatment for that condition are a blessing and unfortunately, in my experience, a rarity.

Tardive Dyskinesia (TD) is a possibly irreversible neurologically based movement disorder most often caused by long term higher dose exposure to antipsychotic medications. Sound scary? It can be, but let's take it piece by piece and put it into its proper perspective.

First, let me clarify what medications we are talking about. The primary risk is from long term, high dose treatment with the older typical antipsychotics which are also known as neuroleptics. The risk of TD is essentially zero for low dose short term use. These medications include Haldol, Navane, Stelazine, Prolixin, Trilafon, Thorazine, Mellaril, Moban, Loxitane, and Serentil. The risk of TD with this group is about 5% per year (this means about 5 of every 100 persons who takes an average dose of one of these medicines for a year will show some TD at the end of that year). Risk increases with age (especially in women), dose, duration, and being nonwhite. There is a lesser risk with a few other non-antipsychotics with similar dopamine blocking action in the brain like metoclopromide, Compazine, amoxapine, and pimozide (Orap). The newer atypical antipsychotics like Risperdal, Zyprexa, Clozaril, and Seroquel have a much lower risk, estimated at less than 0.1% per year (less than 1 in 1000 will show TD after a year). Guess which medicines I prefer to prescribe? The newer antipsychotics, especially Risperdal and Zyprexa, which are called atypical because they block serotonin as well as dopamine. These two have been available longer and are consequently better studied. Clozaril may even treat and reverse TD but has other side effects which cause me to rarely use it. Antidepressants, antianxiety meds, sleeping meds, mood stabilizers, and stimulants do not carry TD risk.

TD is a group of abnormal movements that typically start mildly with subtle involuntary snake-like (choreo-athetoid) and/or chewing-like frequent movements of the tongue and mouth and may progress, especially with continued use of the med, to affect the arms, legs, and other parts of the body in severe cases. TD may be very mild to severe and disabling with the degree usually related to the dose and duration of antipsychotic medicine exposure. TD symptoms are not always caused by medication. Abnormal movements identical to TD occur in some people with other neurologic conditions, some people with schizophrenia, and even in some elderly persons, even without any treatment ever with an antipsychotic medicine.

About 1/3 of TD cases believed to be caused by antipsychotic medication recover completely without any special treatment. Another 1/3 improve with time and treatment but not fully. The final 1/3 do not improve or recover and may progress. The best treatment for TD is using Clozaril or high dose vitamin E; other options exist but are less consistently helpful.

Prevention of TD is the best treatment. Thus, I use Risperdal and Zyprexa conservatively and avoid the older antipsychotics. My patients who take the antipsychotics become very used to the modified AIMS testing I do at a number of the follow-up visits. They are most aware of the finger tapping and tongue examination but are less aware of the way I watch them walk, sit, stand, and how I look for other subtle early signs of Tardive Dyskinesia. I am also watching and listening for signs of the fully reversible and fully treatable false parkinson's, dystonia, and akathisia. I also often advise patients to take vitamin E varying from 200 to 800 IU, depending on age and size, on the chance it may help prevent TD, although there are no studies about preventing TD with vitamin E. Remember though, the risk of TD is zero in short periods of weeks to months and is very very low with conservative doses closely monitored with the atypicals like Risperdal, Zyprexa, and Seroquel. There are also more new medicines on the way. These atypical antipsychotic medicines are, unfortunately, a lot more expensive than the older ones but are just as effective (and usually more so) and bring less potential side effects which brings better compliance and thus even better response. Even their most common short term side effects of helping sleep and sometimes increasing appetite are often helpful. They can usually be given only once a day at night and require no blood or other special tests.

These medications are used for a number of conditions such as schizophrenia, manic depression (Bipolar), psychotic depression, paranoia, tics, autism, as boosters, and for severe impulsive aggression when not responding to lesser treatments. I have seen many situations where Risperdal or even Zyprexa have rapidly prevented or stopped a potentially dangerous situation that would have likely otherwise gone on to hospitalization, arrest, or serious harm.

In summary, the new atypical antipsychotics Risperdal and Zyprexa are wonderful additions to our treatment options. They are often rapidly helpful in crisis situations where other lesser options have failed. I particularly like them for extreme impulsive aggression and rage. Low to moderate doses are usually enough. They are quite safe and easy to use. Although the risk of Tardive Dyskinesia makes them "big guns" the risk of TD is zero on a short term basis. They are also easier and safer to use than other "big guns" like Tegretol, Depakote, Lithium, and the older typical antipsychotics. It is important to remember that we don't often use Risperdal or Zyprexa for aggression unless the situation is severe, other attempts have failed, and they won't be kept unless they are very helpful. Then we can decide how long to keep them at a more leisurely pace after things are calmer.

Quackwatch, subtitled as "Your Guide to Health Fraud, Quackery, And Intelligent Decisions" is a website many will find of great value. This site provides an in-depth discussion of the positives and negatives of many alternative, mainstream, and other health topics, writers, speakers, and trends. Quackwatch is surprisingly broad and detailed with many individual articles on such topics as special diets, ayurvedic medicine, herbs and supplements, aromatherapy, how to spot quackery, multilevel or network marketing, "questionable" cancer therapies, Chinese medicine, chiropractic, homeopathy, iridology, allergies, DHEA, mercury, mental help, Therapeutic Touch, vitamins, "unnecessary" surgeries, weight control gimmicks, misleading and false advertising, power lines, magnetism, the quality of health food store advice, Dr. Chopra, Dr. Weil, psychic advice, low back pain, scoliosis, consumer protection information, and much more. Before trying the latest (or oldest) fad, miracle aid, or other new treatment check it out on Quackwatch! Then discuss your thoughts with your doctor.

You can easily link to Quackwatch and other useful sites from the mental health links page of this site.

This article completes the series on Anxiety Disorders also presented in the Fall 1998 and Winter 1999 issues.

Post Traumatic Stress Disorder (PTSD) first became reasonably understood as clinicians treated war veterans, especially after the Vietnam War. "Shell - shocked" veterans from earlier wars are now understood to have had PTSD or Acute Stress Disorder (ASD) which is a closely related condition that starts quickly and typically resolves more quickly. Now, we understand that traumas such as being kidnapped, assaulted, abused, molested, being victim of a natural or other disaster, or witnessing a sudden traumatic death or severe injury and similar occurrences may trigger PTSD. We also know that different people may respond in different ways depending on various factors in the situation and the person's own vulnerabilties.

For the diagnosis of PTSD the person must have experienced a potentially life threatening trauma and responded to this with severe horror or fear. The symptoms described below must continue for over a month. It is called Acute if symptoms last less than 3 months and is Chronic if they last over 3 months. Usually symptoms start within days to weeks after the incident(s) but may start as much as 6 months later and are then called delayed onset. This is more likely in victims of large natural disasters.

In PTSD there are 3 basic symptom clusters. The first is re-experiencing the traumatic event in varying ways. This may include recurrent and distressing memories of the event and/or nightmares, flashbacks, and intense emotional distress, or physical reactivity when exposed to reminders of the trauma or its after-effects. Second, there are varying forms of numbing and avoidance such as efforts to avoid places and other reminders of the trauma, inability to recall important details of the event(s), decreased interest in day to day life, feeling detached from others, a lessened range of feelings, and feeling one's future has been damaged or shortened. Third, there are persistent symptoms of increased arousal such as exaggerated startle reflex, disturbed sleep, poor concentration, irritability, and/or hyper-vigilance.

PTSD if severe, persistent, and if the trauma is repetitive, especially in a sensitized individual, reflects actual changes in the body and brain chemistry which has been proven in several studies of blood and brain. This can cause inappropriate reactions to otherwise normal events. These brain changes tend to persist but can be lessened or resolved by time and treatment.

PTSD will occur at some time in the life of about 5% of people, with the rate higher in females. Up to 25% of victims of disasters will have PTSD to some degree for some period of time. Most people who experience PTSD will have symptoms disappear with or without treatment in less than a year, although treatment often speeds up recovery and lessens symptoms while helping one to cope and understand the disorder. However, there are individuals whose symptoms may persist for years. PTSD may be complicated by accompanying depression, panic attacks, obsessive compulsive disorder, or phobias. These conditions, substance abuse, and other problems may cause recovery to be more difficult.

Treatment may include psychotherapy, behavior therapy, and/or medication. Therapy techniques especially suited to PTSD include helping the patient process and rethink the event(s), cope with and resolve any loss and grief, lessen the complicating effects of any other condition like depression or substance abuse, and cognitive (thought changing) techniques including desensitization. Hypnosis is sometimes helpful and a newer technique known as Eye Movement Desensitization Retraining (EMDR) shows promise. Medications like clonidine or guanfacine (Tenex) often help the acute symptoms of increased arousal mentioned above while antidepressant antianxiety medications like the SRI's (Prozac, Zoloft, Paxil, Luvox, Celexa), Serzone, Remeron, Effexor XR, or Anafranil and others may help the PTSD symptoms that are most typical later.

Trichotillomania (TTM) is repetitive or compulsive hair pulling. Most commonly, TTM is the excessive pulling out of eye lashes, eye brows and/or hair on the head (scalp). However, the hair pulling may affect other or even all areas of the body. TTM is not diagnosed unless the hair pulling is severe enough to cause emotional or social problems. TTM, like most disorders, may be mild to severe and anywhere in between. A person may have TTM at one point in their life or at many points or even constantly to varying degrees for life. TTM usually affects appearance to only a limited degree for weeks to months and typically the hairs grow back without any lasting damage. In more severe and chronic cases where many hair roots are pulled out, the bald spot may become permanent. Plastic surgery may even be advised.

TTM is most often seen in adolescent girls and young women but may appear at any age and in males. TTM may appear alone but is often associated with an anxiety disorder and/or some depression. The anxiety, such as obsessive compulsive (OCD) features, usually seems directly related to the cause of TTM while the depression seems more often related to the distress of having TTM. More recently, the overlap between obsessive thoughts, compulsive actions, and tics (such as in Tourette's syndrome) has caused clinicians to rethink the overlap between these symptoms and the hair pulling of TTM. TTM both tends to run in families and seems caused by abnormalities in the basal ganglia areas deep in the brain which also play a key role in Tourette's and OCD.

Many cases of minor to moderate TTM in youth will pass with development and time, with or without treatment. Societal forces focusing excessively on the lashes, brows, and hair of teenage girls don't help. Dermatologists see people with TTM, just as they often see patients with so called "neurotic excoriations" or psychogenic dermatitis or neurodermatitis. These patients scratch or pick their skin excessively. Although treatment often helps, the best treatments for TTM are not proven yet. Typically the person with TTM is greatly troubled by the urge to pull or pick but may try to deny it. The urge is often increased by stress. Unfortunately, only a few minutes of giving in to the urge to pull or pick leads to weeks of an obvious bald spot. The youth's guilt and frustration with her lack of control and the parent's upset by the negative social effects can lead to substantial family turmoil as each feels powerless and frustrated at this too often misunderstood disorder.

Treatment may involve behavior management techniques aimed at distracting or redirecting the urge and behavior. Learning alternate stress management as well as education helps those affected to cope better. There are also support groups and a national organization dedicated to helping and educating. Medication treatment follows from the newer understanding of the brain circuitry involved. Frequently, an SRI (Prozac, Zoloft, Paxil, Luvox, Celexa) is a first choice and other medications with dual action (Effexor XR), or a booster or tic medicine such as Pimozide (Orap) may be useful. As in other psychiatric disorders, a combination of psychotherapy and medication is often best, especially for the moderate to severe or chronic and recurrent cases.